Work

The barriers and facilitators of supporting self care in Mental Health NHS Trusts

Year: 2010

Type: book

Abstract: Background \nThe Department of Health has prioritised the need to support individuals in the care they take to maintain their own mental health (2005). Research onthe effectiveness of a variety of self care interventions has been reviewed (DH 2007). Challenges to changing from a culture of ‘doing for’ to ‘doing \nwith’ have been identified (Wilson 2005). \n \nWe use a theoretical framework derived from organisational research to explore how health service organisations change (Edwards 2004), complemented with a strong focus \non service user involvement in the research process (Faulkner 2002). \n \nAims \nTo identify barriers and facilitators to providing self care support in Mental Health NHS Trusts \nTo compare learning about self care support across health service areas. \n \nMethod \nA mixed method cohort study design was used to investigate how self care was supported in three case studies in contrasting Mental Health NHSTrusts. Case studies comprised a range of projects: Wellness Recovery \nAction Planning; peer support groups for people with Personality Disorder;creative arts projects provided by voluntary organisations. \nDemographic and service use data was collected from service users who were new to self care projects, and again nine months later. Service users \nalso completed standard measures of outcomes associated in the literaturewith self care (e.g. empowerment) and qualitative interviews about their expectations and experiences of self care. Informal carers (partners, family \nmembers) were also asked about their experiences, as were staff working in the self care projects. Strategic managers in the case study Trusts were asked about organisational issues around implementing self care policy. \n \nAnalysis of co variance was used to identify variables that might be associated with self care outcomes. A thematic analysis of qualitative interview data explored experiences of self care from a range of stakeholder perspectives. Quantitative findings were further explored through synthesis \nwith qualitative interview data. Online survey was used to consider how findings might generalise to Mental Health NHS Trusts nationally. \n \nLimitations of the study \n \nAnalysis of change in outcomes was exploratory in nature and was used to identify factors that might impact on change. We selected contrasting selfcare initiatives that served varied populations so that we could identify a broad range of barriers and facilitators of supporting self care. Given the \nheterogeneity of our samples, this approach does mitigate againstgeneralising our findings to specific populations, and any conclusions should be read with this proviso in mind. \n \nFindings \nWe report here the most interesting findings indicated by statistical analyses of the data. Although in most comparisons change in outcomes were non-significant, in one site we noted significant reduction of 35% (p=0.005) in A&E attendance, and significant improvement in empowerment and mental health confidence of 3.9 (95% CI 0.8 - 7.0) and \n0.5 (95% CI 0.2 - 0.8) points respectively. \nA second site also showed significant improvement in mental health confidence of 0.3 (95% CI 0.0 - 0.6) points. Choosing to take medication as prescribed was associated with both empowerment and mental health confidence (p=0.007 and p=0.055). \nA higher level of clinical severity at baseline was associated with higher satisfaction with the self care project (B=0.01: 95% CI 0.00, 0.01). A higher quality of life at baseline and more highly rated collaboration with the \nmember of staff participants had most contact with were associated with staying engaged with the self care project (p=0.047 and p=0.020 respectively). Following synthesis of quantitative and qualitative analyses we drew conclusions in a number of areas: \nServices supporting self carePeer support groups and personal plans were strongly indicated as facilitators of self care when well supported. Service users developed strong \npositive identifications where projects focussed on ‘wellness’. \n‘Timing’ support for self care was crucial, with service user control over when to access support for self care (self referral) and how to use that support (flexible; ongoing) fundamental to effective support for self care. \nControl over engagement in self care support is more important than amount of engagement: support for self care cannot be ‘dosed’. \nThere can be no ‘discharge’ to self care: service users were concerned about being ‘abandoned’ by the Trust without a route back at times of crisis. \nSelf care and risk \nEngaging in self care often required the individual to confront difficult issues: self care involves a degree of ‘positive’ risk for service users andservice provider. Overcoming those issues offered rewards(empowerment). \nThe relationship between medication and support for self care was complex: \nsome individuals incorporated medication into their self care while some made a decision to come off medication. \nSelf care and the service user-staff relationship \nAll projects were characterised by a change in the staff role – from provider to enabler – and a change in the service user-staff relationship. \nRelationships were informal and non-judgemental of the service user, but where relationships were ‘too relaxed’ service users could lose confidence in \nthe ability of the service to provide clinical support at times of crisis. \nEmployment of service users as staff on self care support projects offered clear benefits for service users, service user employees and their professional colleagues. However, there were transactional costs of training and supporting service users as staff. \n \nSelf care and social networks \nCarers were positive about self care support and the benefits it offered, butself care impacted on their relationships and could be a source of conflict. Social networks were strengthened through self care, especially where \nsupport was given in settings away from the Mental Health Trust and where new, non-mental health identities were nurtured. \n \nSelf care and the Trust \nTrust staff working in self care support were often highly motivated, expressed high job satisfaction and felt well supported in their teams. They also experienced low morale where they felt job security was low. \nProfessional resistance to a culture change - delivering services ‘with’ rather than ‘for’ service users - was in evidence, but not widespread. Lack of a strategic approach was a more likely barrier to imbedding change. \nThe sustainably of some innovative projects was best achieved by bringing them into the Trust as part of mainstream service provision. However, some \nbeneficial features could be lost through mainstreaming. \n \nSelf care and partnership working. \n \nWhere support for self care was provided outside of mainstream services \nthere were advantages of innovative and flexible ways of working. However,externally provided initiatives were vulnerable to loss of funding. \nMany qualities of self care support aligned well with other policy initiatives(e.g. recovery) and social care priorities (e.g. personalisation), facilitatingcross-sector support. \n \nSelf care policy implementation \nCommunication with the other SDO self care research teams indicated that many features of self care support were common across health serviceareas: e.g. commissioning challenges, culture change. \n \nRecommendations \nWe recommend that Mental Health Trusts should: \nEnable service users to access self care support, including peer support groups, through properly informed self referral \nGive control over how support for self care is used to individual service users through supported personal (self care) planning \nEnsure that clinical and crisis support remains accessible to those who are engaged in self care \nEmbrace ‘positive risk’ at the heart of self care strategy, personal planning, and risk management policy and procedure \nIncorporate joint service user-clinician decision making around medication into personal self care plans \nProvide dedicated training (co-facilitated by service users) to staff teams supporting self care \nEnsure service user employees are effectively managed and \nsupported under appropriate contractual terms and conditions \nSupport carers in their changing role, reaching out to those \npartners and family members who do not identify as careDemonstrate strategic support for self care in order to recruit and retain the best staff in self care support roles \nEnable self care leaders, staff teams and service users to become agents for change through championing their good practice \nWork with commissioners, local authorities and voluntary sector partners to ensure to the sustainability of the best projects \nConsider whether projects supporting self care best deliver health and social care objectives from within, or outside of the Trust \nWe recommend future research in order to: \nDetermine, through controlled studies, the effectiveness of \nspecific self care interventions, incorporating detailed process \nevaluations where interventions are complex in nature \nUnderstand the extent to which innovation is driven by policy \nand/ or by initiatives originating from service user-practitioner \npartnerships, innovative teams and charismatic leaders \nInvestigate the impact of changing staff roles and staff-service user relationships on the staff team, including the integration of service user employees into clinical teams \nExplore the cost effectiveness of supporting self care in order to better inform commissioning decision

Source: Research Repository (Kingston University London)